6 105 Ultrasonographic Achilles Tendon Thickness: Insertional vs. Midportion Reliability If the clinical diagnosis of AT was established, conventional US and Ultrasound Tissue Characterization were performed by the sports physician. Participants were positioned in a standardized manner, prone on an examination table with the ankle placed in maximum passive dorsiflexion and then supported by the examiner’s knee (Supplementary File 1). A multi-frequency 5-16 MHz linear-array transducer (Terason, Burlington, United States) was used. The depth was set at 3.0 cm. The transducer was placed in a transverse position and perpendicular to the Achilles tendon. The sports physician has 15 years of experience with US tendon imaging and UTC data collection and analysis. The procedures were conducted on the symptomatic side. Both sides were examined in cases of bilateral symptoms. The same sports physician simultaneously conducted thickness measurements using conventional US as part of routine care. To minimize recall bias, the thickness measurements on the UTC scans were performed by the sports physician/researcher (RJDV) an average of 16 (standard deviation; SD:7) months after the UTC scan and the measurements on conventional US. The conventional US and UTC scan thickness measurements will be described more extensively below. Asymptomatic population If the inclusion criteria were met, participants were asked to complete a standardized questionnaire that included demographic information, health status, and details on their physical activity and participation in sports activities. Subsequently, a brief physical examination was conducted to evaluate the presence or absence of localized pain upon palpation of the Achilles tendon, as well as to assess localized thickening of the tendon using the Arc sign.18 Finally, the UTC scan was carried out following a standardized protocol on both Achilles tendons by a single trained researcher (TSV). This researcher has three years of experience with US tendon imaging and UTC data collection and analysis. To mitigate the potential influence of anatomical variations, we included 25 left Achilles tendons and 25 right Achilles tendons in our study. The UTC thickness measurements on asymptomatic individuals were performed an average of 5 months (SD: 0.3) after the UTC scan.
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